7
The Cognitive-Behavioural Paradigm
MIchael J. Scott and Windy Dryden
_/~7he theoretical origins of cognitive-behaviour therapy can be traced back
to the Stoic philosopher Epictetus, who in the 'first century AD observed.
that 'People are disturbed not so much by events as by the views which
they take of them'. The implication of this observation is that situations
(like objects in the visual world), are better viewed from some angles than.
from others and that, at least in principle, people choose their orientatio~,. However
a person's 'orientation' is itself influenced by his beliefs about,
himself in relation to the world. Thus if I believe myself to be a football
referee I will watch the football match from a different 'angle' from that
used if I believe myself to be a football spectator. The task of cognitivebehaviour
therapy is to relieve emotional disturbance by helping people
change their maladaptive beliefS and behaviours.
Underlying Theory of Personality and Motivation
From a cognitive-behavioural perspective human experience is viewed as
a product of four interacting elements - physiology, cognition, behaviour
and emotion (Figure 7.1). Thus if I am tense (physiology) when I come
to write an essay this may lead me to think 'I am not going to write a
good essay' (cognition), which in tum might lead me to feel anxious
(emotion) and that might lead me to put my pen down and go for a walk
(behaviour). The effect of going for a walk might be to reduce my
tension (back to physiology), I may then be more inclined to think 'in
reality I actually do quite well on essays' (cognition) and this may make
me feel in tum more relaxed (emotion). In this instance a behaviour'
(going for a walk) has broken down the negative chain reaction. This
behaviour itself may have been energized by my general knowledge
(cognition) that going for walks lifts my mood. Within the cognitivebehavioural
tradition, the primary emphasis is on breaking out of negative
chains via the cognitive and behavioural ports of entry. It should be
noted, however, that it is perfectly possible in principle to break negative
cycles via the physiological port, for example a relaxation exercise
involving tensing and relaxing each muscle group in tum, or via the
156
The cognitive-behavioural paradigm
cognition
physiology emotions
behaviour
Figure 7.1 The cognitive-behavioural model
emotional port, for example playing a favourite music tape. Whilst the
cognitive-behavioural approach to anxiety and depression and other
emotional disorders has concentrated on changing cognitions and
behaviours there has been a shift to include emotions as a port of entry
when it comes to the treatment of personality disorders. To return to
our example, if I thought that 'I am not going to write a good essay' but
also that 'I am a stupid person and wortWess', such a belief might
sabotage all my efforts. Thus, I may not even go for a walk in the first
place. This distinction between thoughts and beliefs becomes more
apparent if we use Persons' (1989) method of conceptualizing clients'
difficulties. She has a two-level model. The first level is one of overt
difficulties, with cognitions, emotions and behaviour reciprocally interacting
(Figure 7.2). The second level is one of covert difficulties, and it is
at this level that core beliefs operate, for example, 'I am stupiď. Core
beliefs are the tacit beliefS people have about themselves and their
relationship to the world. The core beliefs are rarely verbalized and
usually operate at the edge of a person's awareness. They are inferred
, beliefs from a person's responses to a wide range of situations. The core
beliefs are moulded in childhood.
There are reciprocal interactions between levels one and two. My
,belief that 'I am stupiď may make it more likely that I will automatically
think 'I am going to make a mess of something' when confronted with a
task. But if I can change such. automatic thinking (what are called
automatic thoughts) across a range of similar situations then I may
.,eventually change the core beliefs. With disorders such as anxiety and
depression, that is the Axis 1 disorders in the Diagnostic and Statistical
Manual 4th Edition (DSM IV; APA, 1994), automatic thoughts tend to be
the target whereas with Axis 2 disorders in DSM IV, the personality
disorders, the core beliefs are the more direct focus. Individuals differ in
their core beliefs and it is the omnipresence of an individuaľs core beliefs
158
Put off
writing the
essay
/
Anxiety
Core belief
'I am stupiď
Cognitions ....~.-- .~ Emotions ....... - -.....~ Behaviours
'/ am going
to make a
mess of this
essay'
Underlying
psychological
mechanism
Figure 7.2 Person's (1989) model of client difficulties
Perspectives on practice
that makes his or her behaviour relatively predictable and co"nfers on
that individual a particular personality. Beck et al. (1983), for example,
have made the distinction between autonomous and sociotropic"
personalities. The autonomous personality bases his sense of self-identity
on his achievements and would have a core belief of the form 'if I am
not the top then 1 am a flop'. The sociotropic personality on the other
hand believes that he needs the approval of others. His core belief is of
the form 'I am nothing if I do not always have other people's
approvaľ.
Within a cognitive-behavioural paradigm the motivation of an individual
is held to be a product of two sets of beliefs - self-efficacy and" ,
outcome expectancies (Bandura, 1982). Self-efficacy relates to a person's
belief in their ability to perform an action, whilst outcome expectancies
relate to their belief in whether the outcome is worthwhile.
Cognitive-behavioural approaches have been developed differently for
various disorders. It is therefore important to be able to identify and
distinguish the different disorders. To diagnose patients use is made not
only of a clinical interview but also of self-report measures. For example,
the primary theme that emerges when interviewing depressed clients is
one of loss, .of life having lost its flavour, whereas the main theme
permeating an interview with an anxious client is one of threat. A se1freport
measure such as the Hospital Anxiety and Depression (HAD) Scale
(Zigmond and Snaith, 1983) is useful to distinguish the two conditions;
The assessment process
The cognitive-behavioural paradigm
Anxiety
Feeling tense or wound up
Getting a sort of frightened feeling as if
something awful is about to happen
Having worrying thoughts going through
your mind
Inability to sit at ease and relax
Getting a sort of frightened feeling like
butterflies in the stomach
Feeling restless as if you have to be on
the move
Getting sudden feelings of panic
Depression
Not enjoying things the way you used to
Being unable to laugh and see the funny
side of things
Not feeling cheerful
Feeling as if you are slowed down
Losing interest in your appearance
Not looking forward with enjoyment to
things
Being unable to enjoy a good book or
radio or television programme
Figure 7.3 Indicators oj anxiety and depression from Zigmond and Snaith Js
(1983) HAD Scale
clients are asked to report the severity of each of the symptoms in Figure
7.3 on a scale of 0 to 3, and a score of greater than 8 on either sub-scale
has been found to most reliably distinguish clinical cases of a disorder
from non-cases.
A clienťs response to a question on the HAD can be an important
discussion point in the assessment process. For example, a response of
'quite often' to the question on the frequency of panics should lead to
further questioning as to whether the client actually experiences discrete
panic attacks (usually 5-10 minutes' duration), so that a diagnosis of panic
disorder would be warranted rather than for example generalized anxiety
disorder. Different eB treatments have been elaborated for panic disorder
(Clark, 1989), generalized anxiety disorder (Butler et al., 1987) and
depression (Beck et al., 1979). Nevertheless there is some overlap in the
treatment because of co-morbidity, the fact that many depressed clients
are also highly anxious and that many panic disorder clients are often at
'least mildly depressed. The counselling approach used has to take account
of any co-morbidity whilst at the same time having a primary focus on
that disorder which is most debilitating for the individual. A differential
diagnosis indicates the major and minor targets in the clienťs condition.
,Having specific criteria for different conditions provides a basis for
answering the fundamental research question of 'which treatment works
best for which clienť (paul, 1967).
Within the cognitive-behavioural paradigm it is suggested that each of
. the emotional disorders has a particular cognitive content, which can be
assessed with self-report measures with varying degrees of established
reliability. For example, for depression, the Dysfunctional Attitude Scale
159
(W"eissman, 1979) is an often used and well-validated instnllllent.
respondents are asked to register their agreement on a 7-point Like~
Scale to statements such as 'My happiness depends more on other people
than it does on me' and 'I can reach important goals without slave driving
myself'. The cognitive content of a clienťs panic disorder can be made
explicit using Greenberg's (1989) questionnaire, which contains items
such as 'a panic attack can give me a heart attack' and 'I have to escape
the situation when I start having symptoms or something terrible could
happen'.
A cognitive-behavioural assessment requires not only an identification
of cognitive content but also of the typical distorted cognitive processes of
the client. Bums (1980) has listed what seem to be the ten most common
self-defeating thought processes.
1 All or nothing thinking - seeing everything as black and white,
e.g. 'if I am not in complete control, I will lose all controľ.
2 Over-generalization - where it is concluded from one negative
event that other negative events are thereby likely, e.g. 'I wasn't
successful at that and now everything is probably going to fall aparť.
3 Mental filter - seizing on a negative fragment of a situation and
dwelling on it, omitting consideration ofany positive feature, e.g. 'town
was crowded, it was awful, . . . oh yes I did get some great bargains and
bump into some old friends . . . but it was so bad in town'.
4 Automatic discounting - a sensitivity to absorbing negative
information and summarily discounting positive information, e.g. 'yes
I was complimented, but he is nice to everyone'.
5 Jumping to conclusions - where a conclusion is inferred from
irrelevant evidence, e.g. 'everyone stared at me because my stomach
was bloateď. This often involves 'mind reading'.
6 Magnification and minimization - magnifying imperfections and
minimizing positive attributes.
7 Emotional reasoning - using feeling as evidence of the truth of a
situation, e.g. 'I feel guilty therefore I must have done something
baď.
8 Should statements - an overdose of moral imperatives, 'shoulds',
'musts', 'have to's' and 'oughts'.
9 Labelling and mislabelling - emotional reactions are in large
measure a product of the label a person attaches to a phenomenon.
An inappropriate label can produce a distressing reaction.
10 Personalization - egocentric interpretation of interpersonal events
relating to the self, e.g. 'two people laughed and whispered something
to each other when I walked by, they were probably saYing I look
odď.
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The cognitive-behavioural paradigm
Paranoid personality
I am disliked by others
Life is a competitive struggle against external enemies
Therefore, I will excuse myself from blame and failure by attributing blame to others
Schizoid personality
I am a misfit
Life is a difficult place and human relationships are troublesome
Therefore, it is better for me to keep my distance and maintain a low profile
Anti-social personality
I am entitled to what I want
Life is a jungle where dog eats dog
Therefore, I will eat before I am eaten and defy their efforts to tame me
Obsessive-compulsive personality
I am liable to be held responsible for what goes wrong
Life is unpredictable
Therefore, I have to be on guard against anything that might go wrong
Figure 7.4 Core rubrics for personality disorders
These distorted cognitive processes can be found across the full range of
emotional disorders and anyone client will probably be particularly prone
to a few of these processes. There is some overlap between the processes,
it is not suggested that each self-defeating thought pattern is in a watertight
container.
In recent years the attention of cognitive-behaviourists has shifted to a
focus on personality disorders, partly because these disorders may co-exist
with an emotional disorder such as depression or anxiety and make it
more difficult to treat the latter. Forgus and Shulman (1979) have
provided a framework for examining the cognitive content of the
personality disorders by asking clients to perform the sentence completion
exercise below.
1 I am ...
2 Life is ..
3 So I ...
Whilst each individuaľs response will be unique to them, it is argued that
there are families of responses that typify the personality disorders.
Completion of the above sentences by a client would give a brief
summary (rubric) of that client in relation to others and the strategies he
or she uses. Certain rubrics are held to be prototypical of particular
personality disorders; these are called core rubrics (Figure 7.4).
To meet the diagnostic criteria for a personality disorder the client
would not only have to manifest the criteria at the time of assessment but
'would also have to have exhibited such traits by early adulthood. It
follows that the personality disorderd client will have exhibited the same
view of themselves (I am), view of the world (Life is) ahd- strategies
(Therefore), in early adulthood. Within the cognitive-behavioural tram
work the genesis of personality disorders is held to lie in the acquisitio~i
maladaptive beliefs in childhood. These beliefS were probably functi@~
in.Jhe context in which they originated but are maladaptive in the CUtre .
adult situation. To trace the aetiology of personality disorder it is~:'tt
useful to ask clients to complete the framework as if they were itm"
childhood. W~ere the. truthfulness of a cli~nt ~ght be in.question (4'@~
example, a clIent WIth a suspected antI-socIal personalIty dis0 rder)l
evidence would need to be collected from significant others and 'slotted: .
into the framework. In moving from the treatment of emotional disorders'
to personality disorders there is a shift to a more historical focus wiih.-at; greater
emphasis on childhood material. Beck, Freeman and Associates:'
(1990) have developed a similar framework to Forgus and Shulmam"
(1979) using the headings View of self, View of others (a greater emphasis~
than in Forgus and Shulman on the interpersonal), Strategies and Mam
Beliefs, and have applied it to elaborate each of the personality disord~rs:
except for borderline personality disorder (BPD). Beck, Freeman anti:
Associates were unable to explicate the specific thought content of BPDs
and suggest that it is more their thought processes such as all or nothinK .
thinking that are the primary problem. In addition they suggest their.
compulsiveness and low frustration tolerance complicate matters. BecR;, };
Freeman and Associates also suggest that their chronically low self-esteem
has to be a prime therapeutic target.
Young (1990) contends that dysfunctional experiences with early
socializing agents and peers can lead to the formation of Early
Maladaptive Schemas (EMS). He defines EMS as 'extremely stable and
enduring themes (regarding oneself and one's relationship with others)
that develop during childhood and are elaborated throughout an individuaľs
lifetime. These schemas serve as templates for the processing of
later experiences' (1990: 9). They are most in evidence when the person'
shows high levels of affect and overreacts to situations. He identifies 16
maladaptive schemas grouped under five headings.
1 Impaired autonomy - expectations about oneself and the environment
that interfere with one's perceived ability to separate, survive
and function independently.
2 Disconnection - expectation that one's need for nurturing, stable,
trustworthy and empathetic relationships - social or intimate - will
not be met in a predictable manner.
3 Undesirability - the expectation that one will not be desirable to
other people in terms of any of the following: physical attractiveness,
social skills, inner worth, moral integrity, interesting personality,
career accomplishment, etc.
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The cognitive-behavioural paradigm
4 Restricted self-expression - inordinate restriction or suppression of
one's emotions, impulses, natural inclinations or daily preferences in
order to gain the respect of others or avoid guilt.
S Insufficient limits - excessive personal wants that lead to difficulty
meeting others' expectations or one's personal goals.
Young educates clients on how they use schema maintenance strategies
(for example, look for information that supports their schema and discount
information that contradicts the maladaptive schema). He also introduces
the notion of schema avoidance, where the client will not think about
certain material because it is highly affect-laden; this seems consistent with
defensive notions such as denial. The third process he highlights is schema
compensation: engaging in behaviour to compensate for an activated
maladaptive schema (for example, a person who proves to himself and
others how strong he is to compensate for an activated 'weakness'
schema). The focus of therapy is schema change. This is done by the
counsellor identifying and labelling the clienťs schemas and challenging
them. Extensive use is made of imagery to evoke memories and feelings.
What does change mean and how is it brought about?
Change within the cognitive-behavioural paradigm is often synonymous
with symptom reduction and behaviour change. Thus success with an
anxious client would be gauged by say a reduction in the number of and
intensity of the symptoms on the anxiety sub-scale of the Hospital
Anxiety and Depression Scale described earlier. If the anxious client had
also shown agoraphobic avoidance his/her improvement would also be
assessed by his/her ability to venture forth alone. However, for some
conditions such as depression, lasting symptom reduction, that is to say
relapse prevention, is postulated to depend on the modification of core
beliefs. Counselling psychologists are likely to consult not only with
clients who might merit a diagnostic label on DSM IV but also with
clients with problems in living; for both categories attention has been paid
to the question of what constitutes clinical change. (This is an important
question not only from the point of view of whether what the counselling
psychologist does makes any 'reaľ difference to the clienťs life but
also from the point of view of the audits demanded of employers of
counselling psychologists. Jacobson and Truax (1991) have suggested
three ways to operationalize clinically significant change:
1 When the post-test mean score of a client falls beyond the mean of a
comparative dysfunctional group by two or more standard deviations.
2 When the post-test mean score of a client falls within two standard
deviations of a normative group's mean.
.. 163
Perspectives on practice
3 When the post-test mean score of a client is more likely to have been
drawn from the normative rather than the dysfunctional group's
distribution.
For depression, norms for normal and dysfunctional groups are readily
available (Nietzel et al., 1987), making the determination of clinically
significant change easier than for other disorders where comparative data
have yet to be assembled. Cognitive-behaviour therapy is not a single
therapy and it may be that some cognitive-behaviour therapies tum out to
be better than others at bringing about change with some disorders. They
can be categorized under four main headings: coping skills, problemsolving,
cognitive restructuring and structural cognitive therapy. First the
similarities of the cognitive-behaviour therapies are described and then the
differences. The family members share the following characteristics.
1 Therapy begins with an elaborate, well-planned rationale. This
provides clients with an explanation of their disturbance and of the steps
that they will be guided through to help them overcome their difficulties.
In practice this means explaining that it is the interpretation and evaluation
of an event (B) that is the major influence on emotional response
(C), rather than the event/stimulus (A) per se. Analogies are useful to
convey this message. For example 'the mind is like a camera, it depends
on the settings and the lenses you choose as to what sort of photographs
of events you take. It is possible to teach people to choose the settings
and lenses so that you get a more realistic picture of the situation than the
ones that you are typically disturbed about.'
The rationale for the behavioural dimension of therapy is usually
explained in terms of activity as a prerequisite for a sense of mastery or
pleasure. It is therefore necessary to overcome the inertia that emotional
distress can produce.
The cognitive and behavioural dimensions overlap considerably. For
example, a client may refuse to go to the theatre, something he once used
to enjoy; that is, he resists the behavioural task on the cognitive grounds
that 'I know I am not going to enjoy it, so why bother?' This roadblock
would be tackled cognitively by suggesting that the thought he would
not enjoy the play was a hypothesis; he does not have a crystal ball and as
such he needs to conduct an experiment to assess the veracity of his
prediction. At the start of therapy it is also important to outline the time
scale of therapy, the likelihood of success and the importance of
homework assignments.
2 Therapy provides training in skills that the client can utilize to
increase his effectiveness in handling his daily life.
Clients are asked to record events between sessions that they experience
as upsetting. These may be external events such as being criticized
164
The cognitive-behavioural paradigm
by a spouse or internal events, for example a sudden change of mood
looking out of the window watching the traffic go by. Having identified
the triggering events and the emotional responses to these events, clients
are asked to record what they might have said to themselves to get so
upset, that is, to find the Bs of the ABC model. Clients may have greater
or less access to the B depending on whether it is at the forefront of their
mind or at the edge of awareness. Part of the counselling psychologisťs
therapeutic skills lies in making the Bs explicit and then helping the client
challenge whether or not they are valid and useful and by whose
authority they are held. For example, a client who experiences a downturn
in mood watching the traffic go by may have been saYing to himself
'Life is just passing me by, I'm always getting myself into a bad mood, I'll
always be this way, I'm a failure.' A more rational response might have
been, 'I am only 40, life begins at 40, some things I have done well, some
badly. Join the human race.'
3 Therapy emphasizes the client making independent use of
cognitive-behavioural skills outside of the therapy context.
If in the therapy session the therapist had, for example, drawn a clienťs
attention to a constant theme of failure in his Bs, the client would be
alerted that such thoughts could well be triggers for a lowering of mood
outside the therapy session. Consequently the client would be given a
mood monitoring exercise to conduct outside of therapy. First the client
might be instructed to pause when she noticed the first signs of emotional
distress. Then she would have to review her self-defeating talk for themes
of failure. Having identified which theme or themes were operative, she
would then apply the alternative rational response which had been
selected and practised in therapy in order to behave in a way that could
enhance her sense of mastery or pleasure.
4 Therapy encourages the client to attribute his improvement in
mood more to his own increased skilfulness than to the therapisťs
endeavours.
If the client sees his improvement in mood as a product of his own
change in thinking habits and behaviour and can continue using these
skills, the therapist will be able to terminate therapy. Clients can be
prepared to make such attributions by the therapisťs constant emphasis on
the importance of homework assignments. Essentially clients are being
taught a skill for their independent use, and the more they practise it the
more skilful they will become.
The cognitive-behaviour therapies can be categorized under four main
headings, although there is some overlap between them.
Coping skills A coping skill has two components: a self-verbalization or
instruction and a resultant behaviour. A clienťs difficulty in managing
165
Perspectives on practice
particular situations may be due to a deficiency in a coping skill. For
example, a depressed clienťs inability to be assertive, may be due to a
belief that they should never express their own needs, and a consequent
'mumbling' at a time that they should express their needs. The Stress
Inoculation Training (SIT) of Meichenbaum (1985) addresses both the
cognitive and behavioural aspects of coping skills and is the most wellknown
therapy in this category. SIT is aimed at the reduction and
prevention of stress. Stress is viewed as an interaction between the
individual and the environment. Both need to be targeted for change. At
an individual level clients may be taught what to say to themselves and
how to respond in situations that they find difficult. At an environmental
level the client might be encouraged to organize with others, say, a
change in their shift pattern that was more conducive to the workers'
interests.
Problem-solving The problem-solving therapies suggest that it is clients'
deficiencies in problem-solving that lead to the development and
maintenance of their disturbance. Problem-solving therapy (Nezu et al.,
1989) has been the most widely applied therapy in this category.
Problem-solving is conceptualized as involving the following stages:
(a) problem orientation, i.e. 'locking on' to a problem;
(b) precise definition of the problem;
(c) the generation of as many alternative solutions as possible;
(d) choosing the best solution;
(e) planning implementation of the solution;
(f) reviewing progress.
If the chosen solution has not remedied the problem or only partially so,
another 'solution' is chosen, implemented and subsequently reviewed.
This approach can be applied to both impersonal and interpersonal
problems.
Cognitive restructuring The two main therapies under this category are
rational emotive behaviour therapy (REBT; Dryden, 1990) and cognitive
therapy (CT; Beck et al., 1979).
REBT contends that irrationality is a major determinant of emotional
disorder. Ellis (1962) has suggested that much of the neurotic person's
thinking is dominated by 'musts', 'shoulds', 'oughts' and 'have to's'. From
the inappropriate use of these moral imperatives, three beliefs may
develop:
1 'Awfulizing', which is the tendency to make grossly exaggerated
evaluations of negative events.
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The cognitive-behavioural paradigm
2 'Low Frustration Tolerance', which is the tendency to believe that
uncomfortable situations are impossible to bear.
3 'Damnation', which is the tendency to evaluate as 'baď the essence or
human value of self and/or others as a result of the individuaľs
behaviour.
In CT it is maladaptive interpretations of situations thať are viewed as
exercising a pivotal role with regard to emotional distress rather than
irrational beliefs. Beck, Freeman and Associates (1990) contend for
example that an interpretation of a situation that was adaptive in childhood
may become maladaptive in adulthood. For example, an abused
child may well conclude on the basis of his/her experiences that adults
should be approached with gTeat caution, and this may lead to an
unnecessary timidity with other people when he or she becomes an
adult.
In CT clients are asked to collect data on their current maladaptive
interpretations of situations. These interpretations are then cross-examined
and if possible tested out empirically. Thus the counselling psychologist
may, say, seek to lift a depressed clienťs mood by tackling the latter's
inactivity. However, the client might protest that there is little point in
activity because there will be no enjoyment. Rather than get into an
argument with the client as to whether he will or will not enjoy the
activity, in a spirit of what Beck terms collaborative empiricism, the
counselling psychologist might suggest trying the activity as the only sure
way of finding out how it influences mood.
Structural cognitive therapy In structural cognitive therapy (Liotti, 1986)
the concern is with 'deep' structures. Three levels of cognitive organization
are posited:
1 Core level - beliefs (schemata) of the individual that have been
formed, usually during childhood and adolescence, and that are tacitly
held by the individual as unquestionable assumptions about some
important aspect of self and reality.
2 Intennediate level - verbalizable, explicit descriptions of the selt~
other people and the world.
3 Peripheral level - the plans of action and problem-solving strategies
that each individual is able to develop in the day-to-day confrontation
with the environment.
A primary concern in structural cognitive therapy is to make explicit
the core level. The treatment, for example, of an agoraphobic client
would begin with behavioural strategies of helping the client to try going
gradually greater distances alone but therapy would not be terminated
167
Perspectives on practice
when the client had learnt to travel alone. Therapy would also explore
deeper issues such as 'who am I getting out and about for anyway?' In
addition, developmental origins of the disorder would be explored; foť .,
example, an adult agoraphobic may have had a very unwell mother as a
child and found that he regularly had to leave her behind to stay with a
variety of relatives.
The time scale for the application of the frrst three categories of CBT is
brief compared to traditional psychotherapy, typically involving weekly
sessions over three to four months. However, the time scale for the fourth
category, structural cognitive therapy, is considerably longer, typically
18 months, because its goal is to achieve such fundamental changes in the
individual. In many ways structural cognitive therapy reflects the recently
evolved cognitive-behavioural approach to personality disorders. It is well
established that if clients not only have an Axis 1 disorder, such as
depression, but also an Axis 2 personality disorder, then they are less likely
to respond to psychotherapy. As between one-third and two-thirds of
clients presenting with anxiety and depression have a co-existing personality
disorder it has been important to develop treatment strategies to take
account of this (Scott et al., 1995).
Pretzer and Fleming (1989) have suggested the following guidelines for
treating clients with personality disorders. (It should be emphasized,
however, that none of the CB approaches for treating personality
disorders has yet been empirically evaluated.)
1 Interventions are most effective when based on an individualized
conceptualization of the clienťs problems.
2 It is important for the therapist and client to work collaboratively
towards clearly identified shared goals.
3 It is important to focus more than usual attention on the therapistclient
interaction.
4 Consider interventions that do not require extensive client self-
disclosure.
5 Interventions which increase the clienťs sense of self-efficacy often
reduce the intensity of the clienťs symptomatology and facilitate other
interventions.
6 The therapist should not rely primarily on verbal interventions.
7 The therapist should try to identify and address the clienťs fears
before implementing changes.
8 The therapist should anticipate problems with compliance.
9 The therapist should not assume that the client exists in a reasonable
or functional environment.
10 The therapist must attend to his or her emotional reactions during the
course of therapy.
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The cognitive-behavioural paradigm
11 The therapist should be realistic regarding the length of therapy, goals
for therapy and standards for self-evaluation.
The CB approaches to personality disorders are an expression of four
trends in cognitive-behaviour therapy, that make dialogue and perhaps
integration with other psychotherapies more feasible than hitherto.
1 Inclusion of non-conscious processes. There is an acceptance that
schemata and personal rules are inferred constructs and not observable
behaviours which operate covertly and without awareness, though this
does not go as far as acceptance of the notion of a Freudian
unconSCIOUS.
2 Etnphasis on interpersonal process. The salient cognitions to
tackle in the personality disorders are thought to be those concerned
with the view of self in relation to others.
3 Concern for etnotional processes. Whilst cognitive-behaviour
therapists have long accepted the interdependence of cognition and
affect there is increasing attention being given to affect as conveying
information, and as an action disposition. Affect is given the same
status as cognition as a therapeutic means by which the client can
become less disturbed.
4 The itnportance of the therapeutic relationship. Whilst a good
therapeutic relationship has always been held to be a necessary part of
teaching clients the various cognitive-behavioural skills, it is only
recently in the treatment of personality disorders that it is coming to
be understood as a possible laboratory or microcosm of the clienťs
difficulties.
'The,..nature of the relationship between counselľing
,-,psychologist and client
Within cognitive-behaviour therapy the therapeutic relationship has
received much less attention than the technical aspects of counselling.
This has not been because the therapeutic relationship was thought
unimportant but rather that it was taken for granted that a good
therapeutic relationship was a necessary but not sufficient condition for
client change. The cognitive-behaviour therapist would insist that both
technical and relationship skills are necessary for client change, whilst
some other schools of counselling see only the necessity for the
relationship to be considered. The Therapist Client Rating Scale (TCRS;
Bennun et al., 1986) has been used to assess the clienťs view of therapy
sessions and also the counsellor's view. The client form consists of three
scales:
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Perspectives on practice
1 Positive regard/interest
2 Competency/ experience
3 Activity/guidance.
The counsellors form also consists of three scales:
1 Positive regard
2 Self-disclosure/engagement
3 Cooperation/goal orientation.
Both forms are made up of 29 items with each item scaled 1 to 6 (e.g. 1 ==:
very talkative to 6 = very quiet). The instrument has been used with
phobic and obsessive-compulsive clients and a significant positive
correlation was found between the client factor 'positive regarď and
outcome of therapy.
Counsellors providing cognitive therapy for depression are assessed in
research trials using the Cognitive Therapy Scale. The scale has three parts.
Part 1, General Therapeutic Skills, and Part 2, Conceptualization, Strategies
and Techniques, are of equal depth reflecting the equal weighting given to
the personal and technical in cognitive therapy. Part 3 is a brief section in
which the rater indicates any additional considerations, for example a
particularly difficult client, to be taken into account when rating the quality
of the interview. The headings from Part 1 of the Cognitive Therapy Scale
are shown below and the extent to which the counsellor met the goal for
each heading on a scale 0 to 6 indicated: 0 = poor; 1 = barely adequate; 2 =
mediocre; 3 = satisfactory; 4 = good; 5 = very good; 6 = excellent.
Cognitive Therapy Scale
Part 1 General Therapeutic Skills
1 Agenda (0-6)
Therapist worked with client to set an appropriate agenda with target
problems suitable for available time. Established priorities then followed
agenda.
2 Feedback (0-6)
Therapist was especially adept at eliciting and responding to verbal and
non-verbal feedback throughout the session, e.g., elicited reaction to
session, regularly checked for understanding and helped summarize
main points at end of session.
3 Understanding (0-6)
Therapist seemed to understand the clienťs internal reality thoroughly
170
The cognitive-behavioural paradigm
and was adept at communicating this understanding through appropriate
verbal and non-verbal responses to the client, e.g. the tone of the
therapisťs response conveyed a sympathetic understanding of the
clienťs 'message'. Excellent listening and empathic skills.
4 Interpersonal effectiveness (0-6)
Therapist displayed optimal levels of warmth, concern, confidence,
genuineness and professionalism appropriate for this particular client in
this session.
5 Collaboration (0-6)
Collaboration seemed excellent. Therapist encouraged client as much
as possible to take an active role during the session, for example by
offering choices, so they could function as a team.
6 Pacing and efficient use of time (0-6)
Therapist used time very effectively by tactfully limiting peripheral and
unproductive discussion and pacing the session as rapidly as was
appropriate for the client.
Thus in the treatment of Axis 1 disorders the therapeutic relationship
has been an important, albeit infrequently discussed, aspect of the
counselling process. With regard to the counselling of Axis 2 personality
disorders the role of the therapeutic relationship assumes an even greater
importance. For example, if a client has an avoidant personality disorder,
the key feature of the disorder is that others are seen as critical and
demeaning; the therapeutic implication of this is that the counsellor can
very easily be cast as 'just like all the others' and special care has to be
taken to elicit from the client whether anything has been said or done by
the therapist that has upset them. By contrast, a less solicitous stance
would be needed with a client with a dependent personality disorder,
where the key feature is a belief that they cannot function independently.
Thus the counsellor's approach to the relationship is not uniform across
the personality disorders.
;Family, group and organizational applications
The reciprocal interaction of cognitions, emotions, behaviours and
physiology, shown in Figure 7.1 above, takes place in an environment
which may to varying degrees be toxic. The individual may 'inhale' the
fumes through any or a combination of the four ports of entry cognitions,
emotions, behaviours and physiology. The cognitions port is
171
Perspectives on practice
always implicated in emotional distress, though the cogmtIon need not
necessarily be conscious, as it is now well established in cognitive psychology
that people do process information outside of conscious awareness.
The environments which have so far been given consideration in
cognitive-behaviour therapy are current partner or family and the
organizational environment at work. These are now considered in tum.
Current partner and family
In some instances it is recognized that it may be more appropriate to
target the faulty cognitions in the environment rather than the individual.
For example, a depressed child might be better helped by the counsellor
challenging maladaptive family constructs (i.e. family-held beliefs) with
his/her parents and perhaps siblings. So that though the target for change
is the chilďs symptoms, the most efficient way forward might be to
challenge the reasonableness of the parents' expectations of him/her and
what they communicate to him/her about his/her worth. Cognitive
family therapy may in such circumstances be the best way forward. Even
in instances of adult depression, marital therapy may be the counselling
modality of choice rather than individual therapy. It has been found that
50 per cent of women with depression have severe marital problems, and
that the provision of cognitive-behavioural marital therapy, to couples
willing to participate, not only improves marital satisfaction but also
lifts depression. By contrast, providing individual cognitive therapy to
depressed women whilst lifting the depression does not improve marital
satisfaction (O'Leary and Beach, 1990).
Cognitive-behavioural marital therapy involves behaviour exchange
contracts, practice in communication skills and the challenging of beliefs
that disrupt relationships (see Scott, 1989). The beliefs targeted for change
in cognitive-behavioural marital therapy tend to cluster under five
headings.
1 Disagreem.ent is destructive: 'When my partner and I disagree, I
feel like our relationship is falling apart.'
2 Mindreading is expected: 'People who have a close relationship can
sense each other's needs as if they could read each other's minds.'
3 Partners cannot change: 'Damage done early in relationships
probably cannot be reversed.'
4 The sexes are different: 'Misunderstandings between partners
generally are due to inborn differences in the psychological make-up
of men and women.'
5 Sexual perfectionism.: 'I get upset if I think I have not completely
satisfied my partner sexually.'
172
The cognitive-behavioural paradigm
Organizations
The most popular model of stress is a transactional one, that is, str,ess
resides neither in the individual nor in the environment, but arises when
there is a poor fit between the individual and the environment. Within
the work context, stress can arise at the individual (1)/organization (0)
interface. By organization is meant the immediate line managers of the
individual, who may act as conduits of the organization's belief system.
Richman (1988) has contended that individuals may possess vocational
irrational beliefs (VIBS) and that the nature of these will be different at
various points of the career cycle. Similarly, organizations may be
purveyors of vms. A list, by no means exhaustive, of I/O VIBS is shown
below.
Vocational Irrational BeliefS (VIBS)
At entry
1 'I have to show my boss I can do an excellent job or I will be a
failure.'
2 'If I do not like the post right away I will never find a post that is
for me.'
3 'I am bright and talented and therefore should not have to do the
mundane jobs.'
4 'I cannot stand not using my potential.'
VIBS of a demoralizing boss
1 'New recruits must learn the job slowly, going through every single
step.'
2 'New recruits cannot have anything to contribute and therefore
should not have their views considered.'
3 'Beginning recruits should do as we say and not ask questions or
expect feedback unless we choose to give it.'
4 'New recruits should be given the easiest tasks.'
5 'New recruits should be tested out by being assigned to do the
most difficult tasks right away.'
Mid-career
1 'I should have achieved a higher position by this age in my life.'
2 'I cannot stand that I may never accomplish my career goals.'
3 'I am worthless as a person because others of my age have gone
further.'
4 'I cannot stand looking after younger workers who may move up
beyond my position.'
173
5 'I should not level off in my career or redefine my goals because
this.will mean I am weak and not ambitious enough.'
Organizational vms
1 'He/she has done well enough in their specialism, they should not
want to make any kind of change.'
2 'He/she has too many concerns about their family, they can no
longer be trusted as a committed member of the Company.'
3 'He/she should not suddenly try to make a name for themselves at
this stage in their career.'
4 'I should not offer him/her any growth opportunities since their
time here is limited.'
5 'Mid-career workers seem too conflicted and unmotivated to be
given any challenging assignments.'
Resolving many of the so-called 'personality clashes' within industry is
actually about identifying and modifying individual and organizational
VIBS.
Group
The cognitive-behavioural approaches that have been described for Axis 1
disorders are essentially psycho-educational and lend themselves easily to
group treatment. The intent in group cognitive-behaviour therapy, it
should be noted, is different from other group psychotherapies where the
focus is on group processes and dynamics. The group cognitive-behavioural
approach is commended because it is seen as a cost-effective way of
bringing about change. For example, Scott and Stradling (1990) have
demonstrated that group cognitive therapy for depression produces as
much change as individual cognitive therapy. Group cognitive-behavioural
programmes have also been described for anxiety and bulimia. Given the
scarcity of counsellor resources and long waiting lists in the UK, group
cognitive-behavioural approaches are likely to become more commonplace,
with counsellors having difficulty making time for the lengthier
individual CBT treatments of personality disorders developed primarily in
the United States.
Research evidence about efficacy
There is now no disorder to which cognitive-behaviour therapy has not
been applied, including teaching psychotic clients to control their
174
The cognitive-behavioural paradigm
symptoms. But this is not to say that CBT is of demonstrated efficacy for
all disorders; with many disorders systematic evaluations have only just
begun. At least, however, with regard to CBT a beginning has been
made to answer the basic research question posed by Paul (1967), 'What
treatment works best, with which clients, under what circumstances,
delivered by whom?' The most numerous outcome studies at present
relate to depression and anxiety, and the results of these are briefly
summarized now.
Depression is the most extensively researched disorder to which
CBT has been applied. An analysis of 29 randomized controlled trials
(Depression Guideline Panel, 1993) suggested that in acute treatment the
efficacy of cognitive therapy was 47 per cent, of interpersonal therapy was
52 per cent (based on one trial only) and of brief dynamic psychotherapy
was 35 per cent. However, there was a trend for cognitive therapy to
have a lower relapse rate than interpersonal therapy (Shea et al., 1992).
Indeed, cognitive therapy appears to have approximately half the relapse
rate of antidepressant medication (Evans et al., 1992).
Numerous studies have attested to the efficacy of exposure treatment
for agoraphobia, and it has been shown to be superior to a variety of
credible 'placebo' interventions (Mathews et al., 1981). Though the
graded exposure to feared situations is overtly a behavioural strategy,
there are implicit cognitive strategies, about for example the conceptualization
of 'failure' experiences. The typical fmding is that two-thirds
of clients are substantially improved, though even in these some disability
remams.
Most clients 'with agoraphobia also experience some episodes of panic,
and panic disorder has become a focus of treatment in its own right. The
key elements in the treatment of panic are:
1 Systematic exposure to somatic sensations associated with panic (for
example, those associated with hyperventilation, overbreathing).
2 Challenging catastrophic misinterpretations of bodily symptoms.
3 (Usually) breathing retraining.
For panic disorder clients who do not have severe agoraphobic avoidance,
that is mild/moderate agoraphobic avoidance, the typical finding is
that 90 per cent become panic free after 12 one-hour sessions of
cognitive therapy, whereas the comparable figures for applied relaxation
training are 50-55 per cent, and for clients on a waiting list 5 per cent.
These changes have been found to be maintained at one-year follow-up.
For panic disorder clients with only mild agoraphobic avoidance, applied
relaxation training and cognitive therapy seem to be roughly comparable.
In one study (TeIch et al., 1993), involving a comparison of 12 sessions
of group cognitive-behaviour therapy for panic disorder over an eight-
175
Perspectives on practice
week period with a delayed treatment control, at six-month follow-up
63 per cent of the treated patients had recovered compared to 9 per cent
ofcQntr_ols~.
For generalized anxiety disorder Butler et al. (1987) have developed a
treatment package that consists of:
(a) information about the nature of anxiety and what to expect from
treatment;
(b) a cognitive component to address specific anxiety-producing
thoughts;
(c) distraction and relaxation techniques for anticipating anxiety;
(d) in vivo exposure to avoided situations; and
(e) a component focusing on increasing self-confidence, which includes
identification of the clienťs strengths and areas of competence and
identification of and increase in enjoyable activities.
They found their anxiety management programme superior to a waitinglist
control condition at post-test and clinically significant gains were
maintained at follow-up. However, in trials where such programmes have
been conducted but without the in vivo exposure component, the anxiety
management clients have only fared as well as those given non-directive
counselling.
Counselling psychologists can become dismayed that their clients may
not seem to do as well as those in published controlled trials. One of the
reasons for the 'apparent failure' is that clients with a mixed diagnosis are
deliberately screened out from trials. For example, a depressed client with
a drink problem would be excluded from a controlled trial of depression.
As such the exclusion criteria of controlled trials have to be carefully
examined. They may, for example, exclude panic patients who are
housebound or those with a personality disorder. Nevertheless, in a
consecutive series of 100 referrals the frrst author found that in primary
care, 67 per cent met inclusion criteria, depression (23 per cent),
generalized anxiety disorder (25 per cent) and panic disorder (19 per
cent). It is then possible to use the results of outcome studies to evaluate
the majority of cases seen by a counselling psychologist. There is,
however, another difference between controlled trials and counselling
psychology in practice that has to be taken into account, which is of
ensuring that the client has an adequate 'dose' of counselling. In a
controlled trial 'the dose of therapy' is guaranteed: however, the counselling
psychologist in practice has to contend with the pressures of the
waiting list and may often be only able to deliver one-half the number of
sessions delivered per patient in trials. Accordingly the degree of change
expected has to be scaled down. It may be that the norm for depressed
patients by the seventh session should be a 25 per cent reduction in Beck
176
The cognitive-behavioural paradigm
Depression Inventory score. (This can also serve as a marker for progress
when it is possible to provide more sessions.) For generalized anxiety
disorder a 25 per cent reduction in Beck Anxiety Inventory score by the
seventh session may be the appropriate norm.
The continued existence of counselling psychology will probably
depend on its ability to produce demonstrable change and establish an
adequate methodology of audit. One of the advantages of the cognitivebehavioural
approach in this connection is the careful explanation of
procedures and the many areas in which it is already of demonstrated
efficacy.
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